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PubMed1990

AIDS update: an executive report.

Jackson Memorial Hospital, Miami, lost $5.6 million treating AIDS patients last year. Executives at the 1,246-bed public hospital project losses of more than $7 million in 1990. Jackson Memorial's experience is unfortunately all too typical of the effect that AIDS has had on public hospitals. But AIDS is not just a public hospital problem. The trend toward concentration of AIDS cases in public hospitals could have dire consequences for all hospitals in a community, say analysts. But the impact of AIDS on the health care community can be felt at a number of different levels. This executive report also takes an in-depth look at: How case management is being used--or misused--with AIDS patients. How much money state legislatures are allocating for AIDS and what the states are spending the funds on How executives are dealing with various liability issues.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Humoral immune responses in healthy heterosexual, homosexual and vasectomized men and in homosexual men with the acquired immune deficiency syndrome.

In homosexual men, the acquired immune deficiency syndrome (AIDS) is associated with sexual promiscuity and the appearance of circulating immune complexes (CICs) and antibodies to spermatozoa which crossreact with lymphoid cells. A comparative study was initiated to determine whether similar humoral responses existed in 38 heterosexual men lacking sperm antibodies, 13 heterosexuals with sperm antibodies, 42 heterosexual vasectomized men, 22 healthy homosexual men, 26 homosexuals with lymphadenopathy and 16 with AIDS or Kaposi's sarcoma (KS). Sperm antibodies were detected in 12% of the vasectomized heterosexual men, 23% of the healthy homosexuals, 35% of the lymphadenopathy patients and 44% of the men with KS-AIDS. IgG reactive with peripheral blood T lymphocytes was present in only 3% of heterosexuals lacking sperm antibody and 5% of vasectomized men. In contrast, 23% of heterosexuals with sperm antibody, 36% of healthy homosexuals, 31% of men with lymphadenopathy and 62% of KS-AIDS patients were positive in this assay. Antibodies to the neutral glycolipid asialo GM1 were found in none of the vasectomized men, 3% of the heterosexuals without and 8% with sperm antibodies, 17% of healthy homosexuals and 38% and 31% in patients with lymphadenopathy or KS-AIDS, respectively. Lastly, the incidence of CICs, determined by the Raji cell assay, was 0% in vasectomized men, 3% in heterosexuals lacking sperm antibody, 31% in heterosexuals with sperm antibody, 69% in healthy homosexuals, 81% in lymphadenopathy patients and 87% in KS-AIDS. In the homosexuals with lymphadenopathy and KS-AIDS, levels of CICs, T cell-reactive IgG and asialo GM1 antibody were positively correlated (p less than 0.01). Sperm antibody levels were negatively correlated (p less than 0.01) with CICs levels and T cell reactive IgG in heterosexuals and lymphadenopathy and KS-AIDS patients. The results demonstrate that vasectomized men do not manifest at all, and that non-vasectomized heterosexuals with sperm antibodies manifest to a much lesser extent the range of humoral immune responses exhibited by the three homosexual groups. Thus, the route of sperm immunization and/or exposure to autologous vs. heterologous spermatozoa may be of critical importance for eliciting specific immune responses.

Acquired Immunodeficiency Syndrome↗
PubMed1988

The London Lighthouse. A centre for people with AIDS.

In October last year an Evian Health Award was presented to Mr Christopher Spence, director of London Lighthouse, for pioneering the first independent aids hospice against much opposition. The Lighthouse is now open and although the hospice is the core of its work it also provides a range of other services.

Acquired Immunodeficiency Syndrome↗
PubMed1998

Pericardial effusion and AIDS: benefits of surgical drainage.

OBJECTIVES: During the last few years, AIDS has been the main cause of large pericardial effusions in urban settings. We have therefore had to perform surgical pericardial drainage for diagnostic and/or therapeutic purposes in AIDS patients. This study was designed to establish the diagnostic and therapeutic yield of pericardial drainage for these patients. METHODS: We retrospectively reviewed the data of the 13 AIDS patients with a pericardial effusion, referred to our surgical department between December 1989 and December 1996 for surgical drainage and pericardial biopsy. RESULTS: Cytological studies and searches for bacteria, mycobacteria and parasites were all negative. The histology of the 13 pericardial biopsies disclosed three pericardial locations of a Kaposi's sarcoma (all three patients had a pre-existent extra-cardiac location of this sarcoma) and one pericardial location of an already known immature mediastinal teratoma. In the nine other cases, the lesions were aspecific. Four patients died of multivisceral failure within 30 days of surgery. For the survivors, surgical drainage afforded relief and there were no clinical signs of recurrent effusion. CONCLUSIONS: The cause of pericardial effusion in AIDS is still often unknown, even after pericardial biopsy. Here, aspecific pericarditis was the most common diagnosis. Although the prognosis of such effusion in these patients is known to be poor, surgical drainage provided relief for those who survived the post-operative period.

Acquired Immunodeficiency Syndrome↗
PubMed1989

[Therapy of sterility from the viewpoint of females].

361 gynecological out-patients were questioned by means of a standardised questionnaire concerning their attitude towards the following possibilities of therapy procedures in case of sterility: 1. Artificial Insemination by Husband (AIH) 2. Artificial Insemination by Donor (AID) 3. In Vitro Fertilization (IVF) 4. Surrogate motherhood 5. Microsurgery Clearly positive was their attitude towards microsurgery, AIH and IVF. The patients would, in case of a corresponding sterility problem, accept such therapy for themselves. Negative, however, was their attitude towards AID and surrogate motherhood. Acceptance turned out to be significantly higher in regard to the medically and psychologically more precarious procedures like IVF, AID and surrogate motherhood, when asked whether they would tolerate such therapy for other involuntarily childless couples. Acceptance and valuation of procedures repeatedly followed the same order: microsurgery was judged "most moral" and "most natural", then AIH, IVF, AID and last surrogate motherhood. So traditional ideas of standards and values are decisive factors of acceptance. Emotionally the experience of sexuality, the progenitive act and pregnancy seem to belong together. The more a medical-technical procedure will interfere with their privacy the less it will be accepted. No difference in attitude was to be detected in regard to demographic criterions like age or religion. Sterile women, however, were far more prepared to undergo a physically as well as emotionally strenuous therapy in order to have their childwish come true. Personal involvement plays a decisive role in the acceptance of medically and psychologically more precarious procedures like IVF and AID. In comparison the extent of medical-technical efforts, and health risks, seem to be of minor importance.

Adolescent↗
PubMed1992

Cardiac surgery in HIV-positive intravenous drug addicts: influence of cardiopulmonary bypass on the progression to AIDS.

In the last years the number of HIV-positive patients needing cardiac surgery has greatly increased. Cardiopulmonary bypass is suspected to have a role in the progression of HIV-infection to acquired immunodeficiency syndrome (AIDS). From October 1988 to December 1990, 6 intravenous drug addicts underwent cardiac surgery for infective endocarditis at our Department. Preoperative and postoperative absolute lymphocyte T-helper (CD4) and T-suppressor (CD8) counts did not show a close association between the temporary lymphopenia induced by cardiopulmonary bypass and progression to AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed2001

Anaesthesia for insertion of bone-anchored hearing aids in children: a 7-year audit.

Forty-three children, aged 23 months to 14 years, received 102 anaesthetics for insertion of bone-anchored hearing aids, each lasting approximately 30-60 min. Forty of the children had a recognised syndrome involving the head and neck, including Goldenhar's and Treacher Collin's syndrome. The incidence of congenital heart disease was 19%. Pre-existing conditions, anaesthetic technique, grade of intubation, complications and discharge were audited. Sixteen of the patients were classified as Grade 3 or 4 intubations. Over the 7 years, laryngeal mask airway usage increased for airway maintenance rather than tracheal intubation, as did the use of propofol for induction rather than inhalational methods. Intra-operative complications (5.9%) were related to the airway, and postoperative ones (17.6%) mainly to nausea and vomiting. Surgery was performed as a day case in 71% of the patients despite some long-distance travel.

Adolescent↗
PubMed1989

The role of immunomodulators in the treatment of patients with AIDS.

In the last several years, the biologic modification of the immune system has become one of the therapeutic alternatives in medicine. The use of interferon alpha has resulted in both antineoplastic and antiviral effects in patients with AIDS-associated Kaposi's sarcoma. Trials currently underway will determine whether or not this drug, either alone or in combination with zidovudine, is of overall value to patients with early stages of HIV-1 infection. Hematopoietic growth factors, GM-CSF and erythropoietin in particular, offer new hope that the bone marrow suppressing toxicities of certain therapeutic agents such as zidovudine and ganciclovir can be ameliorated, thus allowing the more aggressive use of these important medications. Although a variety of non-biologic immunomodulators have been evaluated in patients with HIV-1 infection, none thus far has shown the clear clinical advantage that has been demonstrated for zidovudine and a variety of clinical trials continue in this area. The area of immunologic reconstitution, although promising in concept, has been disappointing in practice, even in combination with zidovudine. Recent approaches to immunomodulation have included active immunotherapy involving immunization of HIV-1 infected individuals with either inactivated virus or recombinant HIV-1 proteins. Continued investigation of the role of immunomodulation in the therapy of patients with HIV-1 infection should be of value, not only in developing better therapies for patients with HIV-infection, but also in helping develop a better understanding of the nature of the immunologic defects seen in the context of this infection.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Th1/Th2 cross regulation.

We present and analyze a model for the cross-regulation of the Th1 and Th2 helper cell subsets during an immune response by the regulatory cytokines interferon-gamma (IFN)-gamma) and interleukin-10 (IL-10). IFN-gamma, secreted by Th1 cells, can inhibit the proliferation of Th2 cells. Interleukin-10, secreted by Th2 cells, inhibits cytokine production by Th1 cells. Based on these properties, the model shows that responses are expected to be dominated by either Th1 cells or Th2 cells but not both. Which type dominates is shown to depend principally on the relative efficiencies of activation of the responding Th1 and Th2 cells. However, our model, as well as numerous experiments, show that perturbations of the system allow one to switch from a Th2 to a Th1 response, or vice versa. Our model can account for observed outcomes of parasitic infection and may also contribute to our understanding of immune responses to HIV infection as well as to tolerance to self components. It also predicts that in certain parameter ranges vaccination with low doses of live parasites can provide protection against subsequent encounters with high doses that normally induce disease. Experiments by Bretscher et al. (1992, Science 257, 539) on Leishmania major infection are consistent with this prediction. A similar strategy may also be relevant for the design of an AIDS vaccine. Lastly, our results indicate that Th1/Th2 cross-regulation is capable of generating a "sneaking through" phenomenon, and hence it may play a role in tumor immunity.

Animals↗
PubMedDate not supplied

Anti-LAV/HTLV-III antibodies in groups of individuals at high risk for infection in Italy.

We have studied anti-LAV/HTLV-III antibody prevalence in individuals at high risk for infection, such as intravenous drug addicts, hemophiliacs and homosexual men. Among intravenous drug addicts, LAV/HTLV-III infection was first recognized in 1981 and positive serum reactions for anti-LAV/HTLV-III antibody rose in successive years to 53%. Anti-LAV/HTLV-III antibody prevalence was 13.5% in the group of homosexual men, while in hemophiliacs treated with commercial concentrates it was 37% in 1984 and had increased to 45% in 1985. There was a significant correlation between antibody status and concentrate consumption in these patients. Results of studies of anti-LAV/HTLV-III antibody patterns with the Western blot technique suggest that antibodies against core proteins (mainly p25 and p18) and the envelope protein gp40 are always present in asymptomatic individuals and in patients with the lymphadenopathy syndrome, but usually not in patients with full-blown AIDS. These last patients have typical positive reactions only against the envelope proteins gp110 and gp40.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Evaluation of the policy of empiric treatment of suspected Toxoplasma encephalitis in patients with the acquired immunodeficiency syndrome.

PURPOSE: This study was designed to measure response rates and survival in patients with acquired immunodeficiency syndrome (AIDS) and suspected Toxoplasma encephalitis treated empirically and in AIDS patients treated for biopsy-proven toxoplasmosis. PATIENTS AND METHODS: AIDS patients identified at Bellevue Hospital between August 1985 and May 1986, who had abnormal computed tomographic scans of the brain and who received empiric treatment for toxoplasmosis, constitute the empirically treated cohort. A cohort with biopsy-proven toxoplasmosis was identified from Bellevue Hospital neuropathology records spanning 1981 through 1986. Patient records were reviewed with a standardized data form, and tomograms were evaluated by neuroradiologists unaware of the identity of the scans. Survival analysis was performed by the product limit method. RESULTS: Of 38 empirically treated patients, 26 responded clinically and radiographically within four weeks of initiation of therapy. Four of nine patients who underwent biopsy responded to treatment. There was no difference in these response rates (68% versus 44%, p = 0.24). The median survival of the empirically treated responders, from first diagnosis of AIDS to last follow-up, was 422 days. Among the 30 responders, five patients discontinued therapy and four of them had relapses. No relapses occurred in the 25 patients who continued full-dose therapy indefinitely (p = 0.0004). Sixteen of 30 patients (53%) receiving continuous therapy developed toxicity, which required a change in medication. There was no difference in the survival of patients who continued to receive sulfadiazine and pyrimethamine compared with those in whom clindamycin was substituted for sulfadiazine (median, 311 days versus 422 days, p = 0.25). CONCLUSION: A policy of empiric treatment of suspected Toxoplasma encephalitis is satisfactory, and patients who respond to such therapy and continue to take full therapeutic doses of anti-Toxoplasma drugs have relatively long survivals.

Acquired Immunodeficiency Syndrome↗
PubMed2004

The diabetic neuropathies.

BACKGROUND: Diabetes remains the most common cause of neuropathy in the United States and is a significant source of morbidity and mortality, accounting for substantial suffering and billions of dollars in health care expenditures each year. REVIEW SUMMARY: Our insight into the pathophysiology of the diabetic neuropathies has increased considerably over the last decade. aided by advances in the basic science of diabetes itself. A wide variety of potential mechanisms for nerve injury in diabetes has been identified, including the polyol pathway of glucose metabolism, oxidative nerve injury, the deposition of advanced glycosylation end products within the nerve and the effects of vascular insufficiency, among others. Diabetic neuropathy may take a variety of clinical forms beyond the well-known distal symmetric neuropathy, many of which are often misdiagnosed or overlooked entirely, sometimes with serious consequences for the patient. Proper therapy after diagnosis is also critical and may include not only primary management, but also treatment of painful diabetic neuropathy through an expanding repertoire of increasingly effective pharmacologic agents. Though primary treatment trials have not yet provided effective therapies, ongoing and future trials offer continuing promise. CONCLUSIONS: The diabetic neuropathies are exceedingly common, but often improperly diagnosed and incompletely treated. A proper understanding of the mechanisms underlying these diseases and the clinical recognition of their various forms is highly important as appropriate primary and symptomatic management can substantially reduce the morbidity and mortality associated with these disorders.

Aldehyde Reductase↗
PubMed2002

Hemophilia and related bleeding disorders: a story of dismay and success.

Known since the beginning of the first millennium, the hemophilias are among the most frequent inherited disorders of blood coagulation and definitely the most severe. In the 1970s, with the availability of concentrated preparations of the deficient coagulation factors VIII and IX and with the large-scale adoption of home treatment, hemophilia care became one of the most gratifying examples of successful secondary prevention of a chronic disease. Unfortunately, in the early 1980s it was recognized that factor concentrates prepared from plasma pooled from thousands of donors transmitted the hepatitis and the human immunodeficiency viruses. The scientific community reacted promptly to the devastation brought about by hepatitis and AIDS. The last 15 years of the second millennium have witnessed the development of methods that, when applied during concentrate manufacturing, inactivate viruses escaping the screening procedures. The adoption of these measures has reduced dramatically the risk of transmission of bloodborne infections. The production of recombinant factors and their availability for patients' treatment epitomize progress in hemophilia care through DNA technology. Methods based on the polymerase chain reaction (PCR) have unraveled an array of gene lesions associated with hemophilia, permitting improved secondary control of the disease through carrier detection in women from affected families and prenatal termination of their affected male infants. This article will review the aforementioned areas of progress and discuss unresolved problems (such as treatment of patients with antibodies, the risk of new infectious complications, and the issue of secondary tumors). Hopes and expectations for further improvement in the third millennium and particularly the prospects of hemophilia cure though gene replacement therapy will also be mentioned.

Autoantibodies↗
PubMed1999

The hemophilias: progress and problems.

Known since the beginning of the first millenium, the hemophilias are among the most frequent inherited disorders of blood coagulation and definitely the most severe. In the 1970s, with the availability of concentrated preparations of the deficient coagulation factors VIII and IX and with the large-scale adoption of home treatment, hemophilia care became one of the most gratifying examples of successful secondary prevention of a chronic disease. Unfortunately, in the early 1980s It was recognized that factor concentrates prepared from plasma pooled from thousands of donors transmitted the hepatitis and the human immunodeficiency viruses. The scientific community reacted promptly to the devastation brought about by hepatitis and AIDS. The last 15 years of the second millenium have witnessed the development of methods that applied during concentrate manufacturing inactivate viruses escaping the screening procedures. The adoption of these measures has reduced dramatically the risk of transmission of bloodborne infections. The production of recombinant factors and their availability for patient treatment epitomize progress in hemophilia care through DNA technology. Methods based on the polymerase chain reaction (PCR) have unraveled an array of gene lesions associated with hemophilia, permitting improved secondary control of the disease through carrier detection in women from affected families and prenatal termination of their affected male infants. This article will review the aforementioned areas of progress and discuss unresolved problems (such as treatment of patients with antibodies, the risk of new infectious complications, and the issue of secondary tumors). Hopes and expectations for further improvement in the third millenium and particularly the prospects of hemophilia cure through gene replacement therapy will also be mentioned.

Animals↗